Appreciating a good signout

Where: University of Virginia Medical Center, an academic hospital in Charlottesville, Va.

The issue: Improving the signout of patients from one resident to another.

Background

Both attendings and residents at the University of Virginia (UVA) had noticed wide
variation in the ways that residents handed off their patients. “Someone might
spend three minutes saying, ‘Here's my signout. Nothing's going on,’
and then someone else would sit down and spend an hour going through each patient,”
said Margaret Plews-Ogan, MD, FACP, associate professor of medicine and chief of the
division of general medicine, geriatrics and palliative medicine at UVA.

Signout practices were picked up haphazardly, rather than specifically taught to residents.
“There wasn't even any real attempt at standardization, so everybody developed
their own style,” Dr. Plews-Ogan said.

Duty-hour restrictions had also increased the frequency of signouts. “We, like
many institutions, ended up having interesting handoff patterns, like the primary
team would leave at 5, sign out to their cross-cover who would then leave at 8, signing
out to night float. We wondered how the signout changed as you signed out for the
first, second or third time,” she said.

To find out, a team at UVA that included attendings, residents and systems engineers
studied their residents' signouts.

How it worked

The researchers used an appreciative inquiry approach in their quality improvement
project, meaning they found people who were doing signouts well and interviewed them.

Surveys about signout practices (covering topics such as the appropriate purpose,
length and structure of signout) were collected from 89 internal medicine residents.
The residents were also asked to identify which of their peers they thought did the
best signouts. “There were these few people who immediately rose to the top,”
Dr. Plews-Ogan said.

Those top residents were interviewed individually and then brought together for a
discussion about their signout practices. They agreed on some key aspects of a good
signout, including being concise, covering the most acutely ill patients first, and
using a problem-based approach. Including routine laboratory values and medication
lists in signout introduced too much potential for error, they decided.

Results

Working together with other residents and faculty, the signout experts then developed
a new standard template for signouts. As described in results published in the Journal of General Internal Medicine in March, the template called for:

patient's name and demographic information;

a star rating marking the level of acuity from 1 to 3;

chronic diagnoses;

important medications;

inpatient procedures with dates performed;

active, important problems;

anticipated events;

cross-cover tasks and

an empty box for notes on overnight events.

“These intuitively made sense to our housestaff and they did jive with much
of the expert literature around the important components of signout,” Dr. Plews-Ogan
said. As well as implementing the new template, the UVA team developed an educational
curriculum to teach signout best practices to trainees.

Next steps

While the researchers suspect that their template would improve patient care if it
were applied widely, they weren't able to prove that within the scope of this first
study. Dr. Plews-Ogan hopes to investigate effects on outcomes in future research.

Challenges

Hospitals adopting an appreciative inquiry approach may bump into clinicians unfamiliar
with the technique as a method of quality improvement. “It's a new kind of
approach. People may resist it initially because it's different,” said Dr.
Plews-Ogan.

But once they try out appreciative inquiry, they're likely to approve of it. “It's
a lot more fun than a top-down approach, and you often will get engagement and investment
in the quality improvement process from the very beginning,” she added.

Lessons learned

The UVA team also did some observation of residents' pre-intervention signout practices.
They found that night signouts were less than half the length of the day signouts
that preceded them (134 seconds vs. 59 seconds). “Your signout is whittled
down to very little information,” said Dr. Plews-Ogan.

This loss of information with each handoff should be a consideration when hospitals
redesign schedules, she said.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.